Healthcare Provider Details

I. General information

NPI: 1558796862
Provider Name (Legal Business Name): AMANDA MARIE RUNYAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 E DOUGLAS AVE STE 128
WICHITA KS
67218-1011
US

IV. Provider business mailing address

4601 E DOUGLAS AVE STE 128
WICHITA KS
67218-1011
US

V. Phone/Fax

Practice location:
  • Phone: 316-680-6076
  • Fax:
Mailing address:
  • Phone: 316-680-6076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2479
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2479
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: